Employee Information

Employment History

List most recent employment first including summer or temporary jobs. Be sure all your experience or employers related to this job are listed here, in the summary following this section, or on an extra sheet of paper if necessary. No more than 10 years history is recommended.

Driver Information

Do you have any moving traffic violations or accidents in the last 3 years?

Yes

No

Show details below

Date of Violation

Description of Violation (not parking)

Date of Accident

Description of Accident

Date of Accident

Description of Accident

Date of Accident

Description of Accident

Agreement

In consideration of my employment, I agree to conform to the rules and policies of Wells Concrete Products Company and its successors. I understand that my employment and compensation can be terminated without cause at the sole discretion of either the company or myself for whatever reason that the Company or myself may determine. I understand that no Company employee has authority to enter into any agreement for any specific period of time or to make any agreement contrary to the above statement
of Policy.

Will you abide by the safety rules of this company?

Yes

No

Signature of Applicant*

By typing my name here, I hereby declare all statements on this form to be complete and true, and authorize you to consult my previous employers.

Equal Employment Opportunity Data Form

IMPORTANT: To all Applicants – To enable us to meet government reporting regulations and maintain an Affirmative Action Plan, Wells Concrete Products requests you to complete this personal data form. Information will be used solely for government reporting purposes and will be detached and kept separate from your application. Any information that you choose to provide will not be considered by Wells Concrete Products for employment purposes and will be treated as confidential. Your voluntary cooperation is appreciated.

Name

FirstMiddleLast

Position

Gender

Male

Female

Ethnicity

White – (Not of Hispanic origin) All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.

Black – (Not of Hispanic origin) All persons having origins in any of the Black racial groups of Africa.

Hispanic – All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture of origin, regardless of race.

Asian or Pacific Islander – All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands.

Native American or Alaskan Native – All persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribunal affiliation or community recognition.

Veterans

This employer is a Government contractor subject to the Vietnam Era Veterans’ Readjustment Assistance Act of 1974 as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment:

Disabled Veteran: A Veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs OR a person who was discharged or released from active duty because of a service-connected disability.

Recently separated Veteran: Any Veteran during the three-year period beginning on the date of such Veteran’s discharge or release of active duty in the U.S. military, ground, naval, or air service.

Active duty wartime or campaign badge Veteran: a Veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.

Armed Forces service medal Veteran: a Veteran who, while serving on active duty in the U.S. military, ground naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Veteran Status

If you believe you belong to any of the categories of protected Veterans listed above, please indicate by checking the appropriate box below.
As a government contractor subject to VEVRAA, we request this information to measure the effectiveness or the outreach and positive recruitment effort we undertake pursuant to VEVRAA.

I identify as one or more of the classifications of protected veteran listed above

I am not a protected veteran

Protected Veterans may have additional rights under USERRA–the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor’s Veterans Employment and Training Service (VETS), toll-free, at 1-866- 4-USA- DOL.

Voluntary Self-Identification of Disability

Why am I being asked to complete this form:

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you didn’t identify as having a disability earlier.

How do I know if I have a disability:

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.